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07-SEPTEMBER-2008 03:17:44 - Aseptic meningitis Aseptic meningitis Classification and external resources ICD-10 G03. Nonpyogenic meningitis ICD-9 322.0 Nonpyogenic meningitis DiseasesDB 945 eMedicine NEURO/697 Aseptic meningitis, or sterile meningitis, is a condition in which the layers lining of the brain, or meninges, become inflamed and a pyogenic bacterial source is not to blame. Meningitis is diagnosed on a history of characteristic symptoms and certain examination findings e.g. Kernig's sign. Investigations should show an increase in the number of leukocytes present in the cerebrospinal fluid CSF, obtained via lumbar puncture, normal being fewer than five visible per microscopic high power field. The term aseptic is frequently a misnomer, implying a lack of infection. On the contrary, many cases of aseptic meningitis represent infection with viruses or mycobacteria that cannot be detected with routine methods. While the advent of polymerase chain reaction has increased the ability of clinicians to detect viruses such as enterovirus, cytomegalovirus, and herpes virus in the CSF, many viruses can still escape detection. Additionally, mycobacteria frequently require special stains and culture methods that make their detection difficult. When CSF findings are consistent with meningitis, and microbiologic testing is unrevealing, clinicians typically assign the diagnosis of aseptic meningitis-making it a relative diagnosis of exclusion. Aseptic meningitis can result from non-infectious causes; it is a relatively infrequent side effect of medications, and can be an early finding in autoimmune disease. Contents 1 Classification 2 Symptoms and Signs 3 Complications 4 Cause/Etiology 4.1 Infectious 4.1.1 Viruses 4.1.2 Bacteria 4.1.3 Fungi 4.1.4 Parasites 4.2 Non-infectious 4.2.1 Drugs 4.2.2 Systemic Diseases 4.3 Miscellaneous 5 Diagnosis 6 Pathophysiology 7 Treatment/Management 7.1 Anti-pathogenic 7.1.1 Bacteria 7.1.2 Viruses 7.1.3 Fungi 7.2 Supportive 8 Prognosis 9 Prevention/Screening 10 Epidemiology 11 References Classification There is no formal classification system. It is usually by the causative organism if identified. Symptoms and Signs These are varied, depending on the causative organism. There are usually non-specific constitutional symptoms lasting for hours or days. These are then followed by meningitis, characterised by headache, stiff neck, fever, photophobia, drowsiness, and myalgia. A rash may be present, which could suggest a particular virus - for example, varicella zoster. However, a non-blanching purpuric rash is not associated with meningitis and suggests systemic bacterial infection.Realated to polio Complications Seizures, encephalitis and cognitive problems can develop, although rarely. Cause/Etiology The cause can be infectious or non-infectious. Infectious Viruses HSV 1 and 2 HIV Enteroviruses Varicella zoster Epstein-Barr virus CMV Lymphocytic choriomeningitis virus Poliovirus Coxsackie A virus Bacteria Partially treated meningitis Endocarditis Mycoplasma Mycobacterium tuberculosis Borrelia burgdorferi Treponema pallidum Brucella Fungi Cryptococcus neoformans Blastomyces dermatitidis Parasites Toxoplasma gondii Non-infectious Drugs NSAIDs Amoxicillin Azathioprine Methotrexate Intravenous immunoglobulin Isoniazid Allopurinol Systemic Diseases Sarcoidosis Meningioma SLE Wegener's Vasculitis Behcet's disease Miscellaneous Migraine Arachnoiditis Diagnosis Usually the history and examination will arouse suspicion. Confirmation is mainly through CSF findings: Less than 500 mononuclear cells/mm³ pleocytosis should develop with 8-48 hours Normal glucose Elevated pressure Elevated protein No findings which suggest another diagnosis - e.g. negative bacteria antigen tests, no lactate PCR may identify a causative organism Viruses may be cultured from swabs of other areas, such as the throat. Blood tests are rarely helpful in establishing the diagnosis but may be of use to establish baseline chemistry. Imaging is useful in excluding other diagnoses, or identifying other features of infection by an organsim - for example, a chest X-ray may be useful if tuberculosis is suspected. Pathophysiology Invasion into or past the meninges by a pathogen can set up a local inflammatory response. The clinical signs are due to this meningeal irritation - for example, Kernig's sign is due to pain produced by stretching of the inflamed meninges. Treatment/Management Anti-pathogenic If the causative organism has been identified and has a specific therapy, this should be started. Bacteria Even though true aseptic meningitis cannot be caused by pyogenic bacteria, broad-spectrum antibiotic cover should be started as the consequences of misdiagnosing a bacterial meningitis are dire, and relatively easily avoided. For non-pyogenic bacteria, local sensitivities should be taken into account, but generally broad-spectrum is best. Some bacteria are normally sensitive to certain drugs - for example, rifampicin is good for Brucella. Viruses HSV, varicella and CMV have a specific antiviral therapy; most other viruses do not. For HSV the treatment of choice is acyclovir1 Fungi Amphotericin B and fluconazole are the best antifungals in most situations. Supportive This will be the majority of the treatment. Fluids, analgesia and antiemetics should cover most cases. Antipyretics should be used judiciously - fever can be a natural response. Steroids are not recommended unless raised intracranial pressure occurs. Phenytoin and other anticonvulsants can be used is seizures occur, but prophylaxis is not recommended. Prognosis In immunocompetent individuals, the disease is usually mild and self-limiting. Full recovery 5-14 days afterwards is normal. Prevention/Screening Vaccines are available for some organisms that cause aseptic meningitis. Good infection control in hospital, as ever, is recommended. If the causative organism is contagious, steps may need to be taken to isolate the individual and protect the community. Epidemiology Aspetic meningitis is relatively common, with an incidence of around 10/100,000. The male:female ratio is around 1:1. References ^ Tyler KL Jun 2004. Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's. Herpes 11 Suppl 2: 57A-64A. PMID 15319091. v d e Health science Medicine Specialties and subspecialties Surgery Anesthesiology · Cardiac surgery · Cardiothoracic surgery · General surgery · Neurosurgery · Oral and maxillofacial surgery · Orthopedic surgery Hand surgery · Otolaryngology ENT · Pediatric surgery · Plastic surgery · Surgical oncology · Thoracic surgery · Transplant surgery · Trauma surgery · Urology · Vascular surgery Internal medicine Cardiology · Endocrinology · Gastroenterology · Hematology · Hepatology · Infectious diseases · Intensive care medicine · Nephrology · Oncology · Proctology · Pulmonology · Rheumatology Diagnostic Clinical laboratory sciences Cellular pathology, Clinical chemistry, Hematology, Clinical microbiology, Clinical immunology, Transfusion medicine · Radiology Interventional radiology, Nuclear Medicine · Pathology Anatomical, Clinical · Clinical neurophysiology Other specialties Allergy and immunology · Dermatology · Disaster medicine · Emergency medicine · General practice · Geriatrics · Neurology · Obstetrics and gynaecology Fertility medicine, Reproductive medicine · Andrology · Occupational medicine · Ophthalmology · Palliative care · Pediatrics · Physical medicine and rehabilitation Physiatry · Preventive medicine Public health · Psychiatry · Sleep medicine Other Epidemiology · History of medicine · Hospital medicine · Medical education · Medical genetics · Medical school · Osteopathic medicine · Pharmacy · Physician MD and DO · Physician Assistant · Sports medicine · Medical fiction v d e Pathology of the nervous system, primarily CNS G00-G47, 320-349 Inflammatory Meningitis Arachnoiditis, Aseptic meningitis, Tuberculous meningitis - Encephalitis - Myelitis - Encephalomyelitis Acute disseminated - Tropical spastic paraparesis - Cavernous sinus thrombosis Systemic atrophies Huntington's disease - Spinocerebellar ataxia Friedreich's ataxia, Ataxia telangiectasia, Herary spastic paraplegia - Spinal muscular atrophy: Werdnig-Hoffman - Kugelberg-Welander - Fazio-Londe - MND ALS, PMA, PBP, PP, PLS Extrapyramidal and movement disorders Parkinson's disease - Neuroleptic malignant syndrome - Postencephalitic parkinsonism - Pantothenate kinase-associated neurodegeneration - Progressive supranuclear palsy - Striatonigral degeneration - Dystonia/Dyskinesia Spasmodic torticollis, Meige's, Blepharospasm - Essential tremor - Myoclonus - Lafora - Chorea Choreoathetosis - Restless legs - Stiff person Other degenerative/ demyelinating diseases dementia: Alzheimer's - Pick's - Dementia with Lewy bodies - Frontotemporal lobar degeneration mitochondrial disease: Leigh's demyelinating: Multiple sclerosis - Devic's - Central pontine myelinolysis - Transverse myelitis - Marchiafava-Bignami disease - CAMFAK syndrome - Alpers' Seizure/epilepsy Focal - Generalised - Status epilepticus - Myoclonic epilepsy Headache Migraine Familial hemiplegic - Cluster - Vascular - Tension Vascular Transient ischemic attack Amaurosis fugax, Transient global amnesia Cerebrovascular disease MCA, ACA, PCA, Foville's, Millard-Gubler, Lateral medullary, Weber's, Lacunar stroke Sleep disorders Insomnia - Hypersomnia - Sleep apnea Obstructive, Ondine's curse - Narcolepsy - Cataplexy - Kleine-Levin - Circadian rhythm sleep - Delayed sleep phase - Advanced sleep phase Intracranial hypertension Hydrocephalus Normal pressure - Idiopathic intracranial hypertension Other encephalopathy Brain herniation - Cerebral edema - Reye's Other spinal cord disease Syringomyelia - Syringobulbia - Morvan's syndrome - Spinal cord compression Retrieved from http://en..org/wiki/Aseptic_meningitis Categories: Diseases Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page This page was last modified on 27 August 2008, at 13:20
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